Q&A: Therapists on Gender Identity Issues in Kids

Treatment of gender identity conflicts in young children is controversial. Here, NPR talks with two psychologists who take radically different approaches to the issue — one whose treatment aims to help kids feel comfortable with their biological sex, and the other whose approach is to allow the children to live as the gender with which they most closely identify at the time.

Dr. Ken Zucker

Psychologist Ken Zucker is a gender identity specialist who works at the Center for Addiction and Mental Health in Toronto, Canada. His treatment approach is to try to make kids with gender identity issues feel more comfortable with their biological sex.

How do you evaluate whether a child has gender identity disorder (GID)?

We have a psychological protocol we've developed that involves cognitive testing, projective testing, general emotional development, and then a variety of gender specific tasks. One is free play observation, watching what children want to play with — and dress up clothing. We're watching the quality of the play, and we're able to compare patterns with comparison groups of kids such as siblings and kids referred for other issues.

How many children do you typically see?

Usually we see one new [GID] child a week, maybe more. One of the interesting developments is an increase in referrals. Before we had maybe 15, 20 kids on the waiting list. Now, we have 88 people who have called and want their child to be seen for an assessment.

Theoretically, if you got a kid at an early stage — 2 or 3 — even if the child were on the far side of the spectrum and really had a lot of behaviors that seemed to point in the direction of a transgender identity, do you feel like you could take that child and make that child feel comfortable being the sex he or she was born with?

Clinically, I would say yes. I've seen many kids over the years present with all the indicators of GID, and in terms of my quantitative measures they're very extreme. But the follow-up studies I've done, and others too, show [that] a substantial majority of kids seen for GID in childhood show desistance — that is, when they're older they don't want to be the other sex. We just published a study of 25 girls we first saw in childhood and found that only 12 percent seem to have persistent gender dysphoria when they're older. We find similar rates of persistence in boys.

What do you think of the alternative approach — the approach that allows kids to transition to the opposite sex at an early age?

In the last few years, what one is starting to hear about at conferences is this group of therapists and parents who will conceptualize young children as having transgender or gender variant identity. There are some parents and therapists suggesting that the best way to help these kids is to encourage an early gender role change. So, I've seen reports of parents enrolling their 5-year-old biological male child in kindergarten as a girl, for example. That's a very different therapeutic approach than the one I take.

The therapists supporting a child's transition early, I have characterized them in a half serious way as liberal essentialists. On the surface, the approach comes across as very humanistic, liberal, accepting, tolerant of diversity. But I think the hidden assumption is that they believe the child's cross-gender identity is entirely caused by biological factors. That's why I call them essentialists. Liberals have always been critical of biological reductionism, but here they embrace it. I think that conceptual approach is astonishingly naive and simplistic, and I think it's wrong.

I would predict if we followed kids, longitudinally, who are being told "do what you want" — or encouraging early gender role change — they would be much more likely in adolescence or adulthood to go through hormonal and surgical sex change than kids being seen in a psychotherapeutic way, and even probably than kids where people don't do anything active.

What you're saying is that this approach essentially tracks them into a transgender identity?

That would be my prediction, yes.

The therapists and parents on the other side of this issue say that your approach is unethical and distressing and makes kids worse, because you are essentially asking them to change who they are. Doesn't your therapy make them feel bad about who they are fundamentally?

I think when one does therapy there are always mistakes. But I don't think the goal of therapy is to make a child feel bad about who they are. It's helping kids understand themselves better and what might be causing them to develop what I call a "fantasy solution," that being the other sex will make them happy.

What does the research indicate about how people, in general, do psychologically after they transition? Do people who transition seem to do better or worse than people who don't transition?

Well, I think that there are good data showing, for adolescents and adults with gender dysphoria, that as they transition they do better psychologically. Now the question is, is that the case with children as well? I think we have anecdotal data that that may be true, but not systematic data.

If research indicates that transitioning makes people happier, why encourage them not to?

Well, back in the day, the people allowed to transition were carefully screened. All of them were deemed to be reasonably psychologically stable. And those people over time showed better psychological adjustment. Nobody who gets the treatment regrets it by and large. But one of the unanswered questions is, who were all the people not approved for sex reassignment, which is a reasonable percentage. No one really knows what happens to them.

There are so many kids we see in the clinic where the desire to change their sex goes away, for whatever reason. So there are many kids we'd see in adolescence and you'd never have known gender identity was an issue for them in childhood. Not all, but a good segment. The so-called natural history of GID in children is complicated, and to make dogmatic assertions is overly simplistic.

Dr. Diane Ehrensaft

Psychologist Diane Ehrensaft is a gender identity specialist who works in the San Francisco Bay Area. Ehrensaft has encouraged a small subset of her patients to transition to living as the opposite gender, even at an early age.

How many families who have kids with gender issues have you treated?

I would say 50 to 60 families.

And how early do you feel like you can tell that a kid is going to grow up to be someone who lives as a member of the opposite sex?

That's the million-dollar question right there. Here's how I would answer that: As early as toddler age, you can begin to tell that a child is going against the normative gender grain for the culture. For many children they will show it in toy preference, in movements and actions. So that parents who have a little girl will start to notice that their little girl is wanting to play with the trucks more than the dolls, for example.

But that can't tell you that the child is transgender. Usually the earliest you can know comes a little bit later when the child has language. Somewhere between 3 and 4, and sometimes between 2 and 3, a [male] child will begin to say "I'm not boy; I'm girl." So I would say that as early as 2 or 3 you can begin to wonder.

But can you be certain?

I would want us, particularly at this moment in history, to be very humble about our confidence on that question. I think it's a really complicated unfolding phenomenon. I would say I never feel totally confident. But I think that if we really listen to the children, for some children you can know as early as pre-school.

What do you say to Ken Zucker's argument that children this age are flexible, that you can never know?

I would say that I think that there is a subgroup of children who, if we listen to them carefully, will tell us, "I know who I am. And if you let me be who I am, I will be a healthy person. And if you try to bend my twig" — which is what I think Zucker does — "then I will be a repressed, suppressed, depressed person who will learn to do what other people expect of me and I'll hide who I really am."

Do you feel that it is possible to track a child into a transgender identity?

I think it would be very difficult to track a child into a transgender identity.

Where does transgenderism in kids come from? Is it social or biological?

I would say that in the vast majority of cases it's constitutional — biological — the child brings it to us. Which isn't to say that it couldn't also be caused by environmental influences as well. We certainly know cases of a parent who wanted to have a child of the opposite gender and so raised the child as the opposite gender — and basically twists a child into a transgender identity.

But those aren't the children that I'm talking about. If you ask parents, they repeatedly say, "My child just came to me that way." And I would like to say here that usually it's the parents who are maligned for causing it. In the first place, that they did something to their child to allow them to be that way. Or in allowing them to follow their own lead they are encouraging a perverted outcome. So parents get the blame either way.

But I think that our gender identity is not defined by what's between our legs but by what's between our ears — that it's somewhere in the brain. It's pretty much hardwired.

Have you ever had an experience where you felt like a parent came to you and said, "My child is transgender" and you felt, after talking to the kid, that something else was going on that was producing this behavior and that it wasn't native to the child?

I've never had that experience. But what I have had are experiences where parents may jump the gun and come to the conclusion that their kid is transgender rather than gender nonconforming or gender-fluid.

I have a situation right now where I think the jury is out on what the outcome will be. And in that case, I don't promote a transition because this child hasn't told us the whole story yet. The mother wanted him to transition but I thought things were moving too quickly. And in allowing this child to present himself as a girl he got more and more agitated and just seemed chaotic, and I thought that was a good signal that it wasn't right. You do have to be careful.

Answers edited for content and clarity.

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